Hagelin, Elisabet

Abstract [en]

Information contained in medical records is increasingly used for the evaluation of the process of care and to study the health status of individuals. Hence, if recorded information were accurate and reliable, records would be a valuable data source in quality assessment and research.

The main objectives of this thesis were to determine (a) the extent to which information about preschool children's living conditions, health and development and provision of care was completely recorded in Child Health (CH) records; (b) whether information was recorded in accordance with recommendations; (c) whether information was in agreement with other sources and with the care actually provided; and (d) whether information could be reliably transferred to a structured protocol. Three sample records were reviewed and parent-child consultations were observed.

The results demonstrated that different types of information were recorded with varying degrees of completeness and concordance. There was low agreement between record information and information from other sources. Moreover, the observations of health consultations indicated that the care actually provided was more extensive in relation to recorded care. Most types of information in CH records could be reliably transferred to coding protocols.

To increase the quality of medical record data, the CHS staff need to be reminded of the importance of exhaustive documentation of central tasks in CHS. Finally, the arrangement of national instructions for record keeping and a classification system for children's health problems are recommended.